Headlines were made after a kidney was removed from the wrong patient during surgery at St. Vincent Hospital in Worcester this past July. Wrong patient procedures like this one are considered “never events,” according to the Agency for Healthcare Research and Quality: an error that must not occur and indicates serious underlying safety problems.
Misidentification errors resulting in serious patient harm remain an all-too-common occurrence in Massachusetts and nationwide. Indeed, Massachusetts health-care facilities have reported at least seven cases of wrong patient surgery since the start of 2015. See "Cases in point" below.
These cases offer lessons in how even seemingly minor administrative errors can lead to catastrophic harm in the absence of strong systems to prevent patient misidentification and to catch mistakes before they cause injury. “[Identification errors] occur during multiple procedures and processes and can involve nearly anyone on the patient’s health care team,” an August report by the ECRI Institute noted. “As a result, no single strategy can prevent these events; instead, organizations must adopt a multipronged approach to prevent wrong-patient mistakes.”
Two patients with the same name
In the St. Vincent case, two patients with the same first and last names — but different birth dates — had coincidentally received Computerized Tomography (CT) scans at another hospital on the same day several weeks before the mistaken surgery. According to a review by the Department of Public Health’s Division of Health Care Facility Licensure and Certification on behalf of the Centers for Medicare and Medicaid Services, the patient’s “admission and plan for surgery to remove (a) tumorous kidney was based on the other patient’s CT scan results, in error.”
St. Vincent has been given until mid-December to correct deficiencies in patient identification practices or risk losing its eligibility for reimbursement by CMS. The hospital’s CEO Steven MacLauchlan said, “We are on track to meet — and I expect, exceed — all of the expectations and deadlines in the plan we put forth in collaboration with state and federal officials.”